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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802543
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:57:27 PM

Document Has Been Signed on 03/05/2024 12:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ATHERTON BAPTIST HOMESFACILITY NUMBER:
197802543
ADMINISTRATOR:ANGELA LEEFACILITY TYPE:
741
ADDRESS:214 SOUTH ATLANTIC BLVD.TELEPHONE:
(626) 289-4178
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 518CENSUS: 28DATE:
03/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Angela Lee, Administrator TIME COMPLETED:
01:06 PM
NARRATIVE
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LPA made subsequent unannounced visit to complete the annual assessment started on 02/27/2024. LPA met with administrator Angela Lee and discussed the purpose of the visit.

Today LPA reviewed the following.

Operational Requirements: The facility does not accept patients with dementia There 0 bedridden residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: There is a pool on the premises and it is secured as required. Facility has operable smoke and carbon monoxide detectors located in each room and hallways. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the resident’s bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 121.8 – 129.1 degrees F which is not within required range of 105-120 degrees F.
Staffing: There appears to be sufficient staffing at the facility. The administrator's (Angela Lee) certificate has expired, Proof of renewal reviewed. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Identification & Emergency Information, Original Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Some residents files need Physicians reports.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visitors can visit anytime.

Continue on 809C
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ATHERTON BAPTIST HOMES
FACILITY NUMBER: 197802543
VISIT DATE: 03/05/2024
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Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Disaster Preparedness: The facility has an Emergency Disaster Plan but requires updating.
Residents with Special Health Needs: The facility accepts and retains residents with special health needs. One resident with special health needs resides at facility. The staff received training on appropriately caring for residents with special health needs.

Exit interview conducted, deficiency cited, technical advisories, 809D and appeal rights provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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Document Has Been Signed on 03/05/2024 12:57 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/05/2024 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATHERTON BAPTIST HOMES
FACILITY NUMBER: 197802543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature measured between 121.8 and 129.1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Administrator will adjust water temperature and keep a log of the temperature for one week and send it to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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